Compulsory Health Insurance System Research Articles

Mental Health Financing and Purchasing in Four Eastern European Countries

The objectives of this international comparison are: a) to describe and analyze the current status of mental health financing and purchasing in Romania, the Czech Republic, Slovakia, Bulgaria; b) to identify common trends as well as national specifics in mental health financing and purchasing and find opportunities for transfer of knowledge and experience among the countries, c) to improve understanding of the attitudes towards mental health services in the countries. Methods: The country-specific information was obtained by a questionnaire that was developed by the research team in the project “Finance and Mental Health Services Training in Czech Republic/Central Europe”, sponsored by the U.S. National Institutes of Health John E. Fogarty International Center. The questionnaire includes both quantitative and qualitative information on the mental health policy, health services, financing and purchasing.Results: In all countries, the tax-financed system was transformed to public health insurance one, though the countries differ in the implementation. The Czech Republic and Slovakia have multiple health insurance funds; Romania has the national unique social health insurance fund administrated by the National Health Insurance House through its district houses and Bulgaria run one national health insurance fund. The compulsory social health insurance system secures that citizens have access to mental health services. The Czech Republic and Slovakia do not have any separate budget for mental health care; mental health care is financially integrated with other services. In Romania is the Mental Health National Program developed by the Health Ministry through the national unique social health insurance fund. Bulgaria is the only country in which inpatient care for the mentally ill is financed from the state budget and outpatient care is financed from health insurance.

Cerebral Palsy Among Term and Post-term Births

Preterm birth is a strong predictor of cerebral palsy (CP), with risk of CP increasing with earlier delivery. There is a lower individual risk of CP among infants born at term, but even so, most infants with CP are born after 36 weeks of gestation. Little data are available within this range of term births on the association between risk of CP and gestational age in infants born at term. This population-based study investigated whether risk of CP is associated with timing of birth in the term and post-term period. Information obtained from the national health and insurance registries in Norway was used to identify 1,682,441 singleton live births between 1967 and 2001 with a gestational age of 37 to 44 weeks. Linkage to other national registries provided follow-up data for this cohort through 2005. The primary study outcome measure was the absolute and relative risk (RR) of CP among children who survived to at least 4 years of age. The gestational age was estimated using information based on the last menstrual period. Data from the Norwegian compulsory health insurance system identified 1938 term and post-term children with CP (1.15/1000 births). The lowest risk of CP was found among infants delivered at 40 weeks; the prevalence was 0.99/1000, with a 95% confidence interval (CI) of 0.90–1.08. Compared with term delivery, CP risk was higher with both earlier or later delivery: prevalence at 37 weeks was 1.91/1000 (95% CI, 1.58–2.25) with a RR of 1.9 (95% CI, 1.6–2.4); at 38 weeks, 1.25/1000 (95% CI, 1.07–1.42) with a RR of 1.3 (95% CI, 1.1–1.6); at 42 weeks, 1.36/1000 (95% CI, 1.19–1.53) with a RR of 1.4 (95% CI, 1.2–1.6); and after 42 weeks, 1.44 (95% CI, 1.15–1.72) with a RR of 1.4 (95% CI, 1.1–1.8). The association of CP risk with gestational age was even stronger with ultrasound-based gestational age than with last menstrual period for infant subgroups born at 37 weeks (prevalence, 1.17/1000 [95% CI, 0.30–2.04] with a RR of 3.7 [95% CI, 1.5–9.1]) and at 42 weeks (prevalence, 0.85/1000 [95% CI, 0.33–1.38] with a RR of 2.4 [95% CI, 1.1–5.3]). The RRs for gestational age were unaffected by adjustment for infant gender, maternal age, and several socioeconomic measures. These findings show that risk of CP is lowest at 40 weeks of gestation and is higher before and after this.

Andreas-Holger Maehle, Doctors, honour and the law: medical ethics in imperial Germany, Basingstoke, Palgrave Macmillan, 2009, pp. viii, 198, £50.00 (hardback 978-0-230-55330-9).

Research on the history of medical ethics in Germany has so far focused on the Third Reich and the Weimar period. Except for a few studies we hardly know how medical ethics developed and was shaped in the Kaiserreich. A new book by Holger Maehle provides for the first time a comprehensive overview on doctors’ professional ethics in Germany from the foundation of the German Empire in 1871 to the beginning of the First World War. In order to understand why there might have been a German Sonderweg (a unique way) in medical ethics, one has to remember that the professionalization of German doctors was more closely linked to state interventions than that of physicians in the United States or in Britain where a more liberal system prevailed. A special feature of the professionalization of medicine in Germany was the growing dependency of the medical profession due to the compulsory health insurance system which Chancellor Otto von Bismarck had introduced in the 1880s. “Medical professional ethics in Imperial Germany was”, according to Maehle, “as much about defusing competition among doctors as about enforcing solidarity vis-a-vis the health insurance boards” (p. 3). The Penal Code of 1871 also had an important influence on medical ethics in the Kaiserreich, especially those paragraphs dealing with physical injury and professional secrecy. The first chapter of this book shows that German doctors sought the backing of the state in disciplining their colleagues. An interesting fact is that in Germany the direct model for professional courts of honour was the Lawyers’ Ordinance of 1878. In 1899, a disciplinary tribunal was introduced in each of the twelve Prussian medical chambers, while in Bavaria, for example, this was the case only thirty years later. Examining the activities of these medical courts of honour one discovers that a relatively small number of cases were in fact brought before these tribunals, dealing mostly with maltreatment or with patients’ complaints. The most frequent reason for disciplinary punishment was excessive advertising, which was regarded as dishonourable and quack-like by the medical profession. Likewise, it does not come as a surprise that a large number of accusations were made by other doctors, indicating the fierce competition in the medical market in the age of professionalization. The second chapter discusses the codification of secrecy for medical staff in Germany, shedding light on the medico-legal debate on the priority of public versus private interests in cases where doctors were asked to give evidence in court. A good example of the way in which the doctor’s duties to the general public ought to carry more weight than his duty to the individual patient and to confidentiality is the debate on the combat of venereal diseases in Imperial Germany, culminating in the decision of the Supreme Court in 1905. One of the most fascinating and illuminating chapters in this book is that dealing with patients’ information and the right to self-determination. Germany can certainly be considered a pioneering state in this respect. In 1894, the German Supreme Court endorsed the legal view that medical interventions constituted physical injuries. This meant that any operation (except in medical emergencies) required the patient’s consent. The fourth chapter deals with the ethical views that were expressed in late-nineteenth- and early-twentieth-century writings about doctors’ duties, considering especially the issues of truth-telling, euthanasia and abortion. The main focus lies on Albert Moll’s seminal book on medical ethics, published in 1902. Maehle’s conclusion is convincing, although it does not come as a surprise for those who are familiar with the medical history of this period. Medical ethics in Imperial Germany were guided more by political considerations, notions of honour, and professional reputation than by any concern for patients’ interests.

Patients at risk for long-term sick leave because of low back pain

Background context Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs. Purpose To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non–return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation. Study design/setting A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system. Patient sample Three hundred and forty-six patients. Outcome measures Patients unable to resume work within 3 months of sick leave were classified as bad outcomes. Methods Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires. Results Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02–1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02–1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21–3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17–0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25–2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4). Conclusions A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work.

Primary health care development in 2002–2006 in Lithuania: Will we achieve the objective set?

The aim of this study was to identify the changes in the development of primary health care in 2002-2006 and to predict its potential results in 2008, based on various criteria (indicators). Data from the compulsory health insurance system "Sveidra" have been used for the analysis. A share of the private primary health care institutions, the persons enrolled with them, and visits in such institutions from all primary health care institutions during the study period have significantly statistically increased (average annual changes were 6.9%, 22.2%, and 27.2%, respectively). In 2008, this part would make up 61.0%, 30.6%, and 27.2%, respectively. The proportion of persons registered with family doctors and the number of visits to family doctors were significantly increasing (average annual changes were 22.5% and 27.2%, respectively). It is predicted that this part would make up 27.8% and 35.2% in 2008. More detailed analysis has shown that relatively more young and working-age persons (aged 18-44 years) were enrolled in private primary health care institutions. It is in particular evident in Vilnius and Kaunas where the choice of such institutions is high. The number of persons registered with family doctors was increasing in both private and public institutions (average annual changes were 22.5% and 8.3%, respectively; P<0.05). In private institutions, the proportion of persons registered with local district pediatricians was also significantly increasing. The study results have shown significant differences in the developments of primary health care in 2002-2006 by various indicators. The objective defined in the strategy of restructuring will be achieved in 2008 only in respect of the number of institutions. Assessing by the aspect of services, the results achieved will be approximately two times lower. The practice of the institution of the family doctor is becoming more intensive in both private and public institutions.

Trends in the Use of Psychotropic Drugs in Taiwan: A Population-Based National Health Insurance Study, 1997-2004

Trends in the Use of Psychotropic Drugs in Taiwan: A Population-Based National Health Insurance Study, 1997-2004

Reformoptionen für einen zukünftigen Risikostrukturausgleich in der GKV

AIM OF THE ARTICLE: The risc structure compensation scheme within the German compulsory health insurance system is intended to enforce the principle of solidarity all over the statutory health insurance and not only within the different sickness funds. Differences in the contribution rates should not reflect different risc profiles, but the differences of the efficiency in social care. The criticism against the current adjustment system in Germany is multifarious and points e. g. on the missing orientation to morbidity. This article follows the question, whether this criticism is valid. The variables and methods, which are currently used to calculate the risc structure adjustment are discussed and compared to an alternative proposal for the future form of the risc structure adjustment, which includes both a higher orientation to riscs and incentives for social health insurance funds to decline the costs for the social care system on long-term. Currently, for the calculation of the risc structure adjustment the following variables are used: age, sex, income, number of family members who are exempted from contributions and persons who get occupational disability pension, and number of insured persons who are registered to an accredited Disease-Management-Program (DMP). Especially the last variable includes a high control effort, because the higher co-payments of the adjustment system are aligned to the voluntariness of participation and active collaboration of the patients in DMP. The argument, a further development to a morbidity-oriented risc structure adjustment leads to less cost management of the sickness funds is not totally correct, because not actual, but standardised costs are the basis for compensation. On the other hand the morbidity determined cost components should not totally be adjusted, as a proper distribution of savings to the risc structure adjustment and the single funds would still be an incentive for cost management and prevention. An ongoing refining of the risc structure adjustment might cause new incentive problems. Instead a morbidity orientated risc structure compensation scheme should leave a part of the savings due to better social care structures in the sickness funds and should include outpatient care parameters. The change to a new honorarium system could create a better data basis for this improved form of risc structure adjustment in the future.

Historische Entwicklung und aktueller Stand der Richtlinien-Psychotherapie in Deutschland

The directives for psychotherapy, which were established in 1967 for the compulsory national health insurance system, had a strong influence on the subsequent development of psychotherapy in Germany. This article depicts the historic conditions and the general framework of the directives for psychotherapy as well as their development in the decades following. Finally, possible future perspectives and risks are discussed.

Winners and Losers: Expansion of Insurance Coverage in Russia in the 1990s

This study sought to describe the evolution of the Russian compulsory health insurance system and to identify factors associated with noncoverage. Data from successive waves of the Russian Longitudinal Monitoring Survey (1992-2000) were analyzed. Insurance coverage grew rapidly throughout the 1990s, although 11.8% of the country's citizens were still uninsured by 2000. Coverage initiation rates were greater at first among citizens who were better off, but this gap closed over the study period. Among individuals of working age, coverage rates diminished with age and were lower for the unemployed, for the self-employed, and for those residing outside Moscow or St. Petersburg. The growth of insurance coverage in Russia slowed toward the end of the 1990s, and gaps remain. Achievement of universal coverage will require new, targeted policies.

Genuine federalism in the Russian health care system: changing roles of government.

The reforms that have affected the Russian health care system since the breakup of the Soviet Union, principally those in the general administration of the Russian Federation, have suffered from inconsistency and the absence of a strategy. The various reforms have caused a shift from a national health system characterized by highly centralized management and control, typical of the totalitarian uniform state, to a highly decentralized but fragmented multitude of state systems. Each of these systems is relatively centralized at the local level and run by local administrations with limited government infrastructure and experience. The role of government in the emerging system, and in particular the role of the federal government, remains ill defined. As a result, there is a grave risk that the Russian health care system may disintegrate as a national system. This undermines (a) the prevailing universal and fairly equitable access to care, (b) stabilization of the system following a long period of transition, and (c) the long-term reform that is required to bring the Russian health care system up to par with the health care systems in other developed countries. A rapid transition to a genuine federal health system with well-articulated roles for different levels of government, in tandem with implementation of the 1993 Compulsory Health Insurance System, is essential for the stabilization and reform of the Russian health care system.

Digital patient assistants: privacy vs cost in compulsory health insurance

Many countries have a compulsory health insurance system. Compulsory health insurers charge income-related fees as opposed to private health insurers who charge risk-related fees. Compulsory health insurance is based on solidarity among policy holders and can give them more privacy than any private health insurer can. As an example, the present paper considers the German health insurance system, and discusses how the charging and clearing of medical services can be implemented so as to support both the legitimate privacy interests of patients and physicians and the health insurer’s interest to control the overall cost. A cryptographic solution is presented that is based on digital patient assistants, that is, personal palmtop computers, organizers or personal digital assistants (PDAs). Patients are, therefore, able to manage their own health insurance certificates, referrals and prescriptions. Although still too expensive for large-scale introduction, digital patient assistants have a number of significant advantages over any chip-card or paper-based system: (1) significantly more efficient and reliable data communication between the various health-care providers involved in treatment; (2) real patient privacy through direct and off-line communication between digital patient assistants and physicians’ practices; and (3) a huge potential to develop telemedicine in a privacy oriented way. Finally, one possible implementation is presented in more detail. The paper also shows how compulsory health insurers can use this solution to control their overall costs.

La réforme du financement du système de santé en Russie

Health reforms have been implemented in Russia for nearly a decade now. The first reform sought to improve the budgetary system for funding medical expenditures. In 1991, a health insurance system was set up. The major characteristics of Russian reform are: the complexity of the system of compulsory health insurance, which was introduced in bits and pieces ; the decentralization of reforms and regional differences in transitional models; and the attempts to oppose reforms and re-establish the former system for financing health care. The budget crisis has made it even more necessary to go on with reforms: a new phase was announced in 1997. The main tasks are to strike a balance between guarantees for access to free health care and public funds for such care; to correct financial flows to medical expenditures so as to overcome the piecemeal nature of health insurance; and to develop democratic procedures for administering and controlling the health system.

Health care reforms in Russia: The example of St Petersburg

This paper describes the changes being introduced into the Russian health care system, particularly the introduction of a compulsory social health insurance system which is paralleled by encouragement of independent health insurance. An example of the implementation of these changes is provided by the early developments in St Petersburg. The effects of the likely changes on health care providers and users are discussed. It is argued that in the light of these reforms, as well as change in other countries, a revision is necessary in the perspectives adopted by geographers of health care to compare national health systems.

Consultation-liaison psychiatry in Australia

Consultation-liaison (C-L) psychiatry as a service entity has developed slowly and to a variable extent in Australia despite the presence of factors conducive to its development. These include a compulsory national health insurance system and a favorable disposition to the biopsychosocial model and to psychoanalytic ideas. C-L psychiatry, however, does enjoy a high profile in many undergraduate medical and postgraduate psychiatry teaching programs. Research on C-L psychiatry is emerging, complementing a strong history of research in psychosomatic medicine. An Australian and New Zealand C-L psychiatry interest group is being formed. Collaboration with the MICRO-CARES Consortium and the European Consultation-Liaison Workgroup is proving to be a great stimulus.

Old age in the sun.

In 1984 Australia's culture and its social structure are as much influenced by the United States as by Britain. The fast food restaurants, the drive in movie theatres, and the large, slowly driven cars give the visitor the impression that he might be in the American midwest (until someone starts speaking) ; and for many Australians the profusion of advertising and cut price promo? tions reflect the healthy virtues of capitalism. Yet the Labour party is in office, and successive governments have accepted responsibility for a wide ranging programme of social welfare. Australia's health system?and especially its arrangements for the care of the elderly?provide a prime example of the in? compatibility of social welfare and entrepreneurial capitalism when brought together in a marriage of convenience. The British influence seen in Australia should not be equated with attitudes found in contemporary Britain. Many Australian doctors emigrated from Britain after the second world war, disenchanted with socialism and austerity. They remain strongly opposed to any suggestion of socialised medicine on the NHS pattern: the Australian Medical Association speaks the same language (and has the same public image) as the American Medical Association. Doctors are seen by politicians and the public as rich, powerful, and greedy, though individual patients often have the same affection and respect for their family doctors as in Britain. At present the doctors and the government are enmeshed in bitter arguments about the financial implications for patients and doctors of plans for a new system of compulsory health insurance. Medicare. This is the context in which care of the elderly reflects the continuing conflict between society's aspirations for compassionate provision for their needs and the ingrained opposition of many doctors and businessmen to what they see as governmental interference. Australia has not escaped the worldwide economic recession and its economists share the conviction of those in Europe and the United States that public spending should be cut?and that includes spending on the elderly. The current financial crisis has focused public attention on the rapid growth in the past decade of the numbers of nursing homes and other institutions for the elderly. Many of these institutions are run as money making businesses, but most of the occupants' fees are paid by the government. Attempts by the government to grapple with this drain on its finances have run into two obstacles : the conserva? tism of the medical profession and the Australian tradition that making money fast is a virtue. And to complicate the story further for the overseas visitor Australia is made up of six autonomous states and two territories, each of which has a slightly different system for the care of old people while much of the money that pays for that care comes from taxation controlled by the Commonwealth (federal) government.

The problem of lowering the age limit for breast cancer screening in women under the compulsory health insurance system (author's transl)

The problem of lowering the age limit for breast cancer screening in women under the compulsory health insurance system (author's transl)

The Dental Care System in Norway

One of the lowest population-to-dentist ratios in the world is enjoyed by Norwegians whose two tuition-free government dental schools graduate a total of 148 students annually. Schoolchildren aged 7 to 14 receive free operative dental treatment in school clinics; adolescents are treated on a space-available basis. A system of compulsory health insurance enables adults to receive treatment from private practitioners at reduced fees.

Cost of Medical Care: The Expenditures for Medical Care of 455 Families in the San Francisco Bay Area, 1947-1948

The Heller Committee for Research in Social Economics of the University of California has presented a study of the expenditures for medical care of 455 moderate income families in the San Francisco Bay area in 1947-1948. After extensive analysis of the expenditures for medical care, the composition of the families, the illnesses for which medical care was required, the types of medical care required, and the amount of prepayment coverage, this report concludes that expenditures for medical care can be burdensome and sometimes disastrous and that "the only way that real protection can be accomplished is through a system of compulsory health insurance at least for the low- and moderate-income groups in our population." This conclusion is not supported by the findings of the study. The great majority of the families studied had medical expenditures that could not be called disastrous in relation to their income. The most common illnesses

A Method of Making Actuarial Estimates for a Compulsory Health Insurance System

T1HE actuarial basis of a compulsory health insurance system, in the final analysis, resolves itself into a problem of simple arithmetic. Obviously enough money must be raised under the system to pay for the benefits provided thereby, and benefits provided under the plan cannot be more extensive and complete than what can be supported by the health insurance fund. In other words, under a compulsory health insurance plan, as with all other things, it is impossible to get something for nothing, and all that is offered under the insurance system must be paid for out of funds collected from the employer, employee, and/or the government. There are at least two approaches to the problem of determining the costs of such a sytem. One may fix arbitrarily the maximum amount of contributions that it appears wise or prudent to levy for the plan, thereby determining the amount of money with which can be bought. Or one may determine what appears to be the minimum number of which should be offered in bringing medical care to the desired number of persons, and then, upon a basis of these needed services, determine how much money will be needed to pay a fair price for those services. In either case it will be necessary to estimate as accurately as possible (a) the total or per capita cost of to be afforded, and (b) the total or per capita contribution which will be collected to pay for the services. Since compulsory health insurance is a new field to the people of this country, both the amount of the levy which can and should be collected for the support of the schemie and the number and nature of what are to be called basic medical services afforded to the largest possible number of the population are matters that, for the want of a better method, must be more or less arbitrarily determined. But a start is needed, and enough under the health insurance system must be offered to meet at least the needs of the largest number of persons possible at a cost that will not be over-burdensome for the individual, the employer, or the state or federal government. Otherwise, the plan cannot survive, and cannot be instrumental in meeting the difficulties encountered under the system of the private practice of medicine.